F695 — Respiratory Care — Tracheostomy and Suctioning
Failure to provide tracheostomy care, suctioning, ventilator management, oxygen therapy, or other respiratory care consistent with professional standards. Often cited with IJ when a resident has a respiratory event the facility was not equipped to handle.
Reg cite · 42 CFR 483.25(i)
146 surveys in corpus
27 states
What surveyors look for
- Trach care performed q-shift and PRN per care plan, with documentation including stoma assessment
- Suction supplies stocked at bedside, including spare trach tube of same size and one size smaller
- Staff competency check-offs current for every nurse caring for the resident
- Emergency equipment (BVM, oxygen, suction) tested daily and accessible within seconds
Common gotchas
- Bedside suction with empty canister or no sterile water/saline
- Staff unable to demonstrate emergency trach replacement
- Oxygen tubing changed less frequently than facility policy or replaced with kinked tubing
- Resident's primary nurse not signed off on trach competency
Real survey examples
From CMS-published 2567s in our corpus. Resident identifiers redacted.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide safe and appropriate respiratory care for a resident when needed.
Based on observations, record review, and interviews the facility failed to ensure oxygen was administered
at the prescribed flow rate, failed to ensure handheld updraft nebulizer masks were covered when not in
use, and failed to ensure oxygen concentrator humidifier bottles were sufficiently filled for two (Resident and Resident) of two residents reviewed for respiratory care.
Findings included:
During an interview on [date] at 3:24 PM, t…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
She also said the updraft mask not being covered could cause the spread of infection, and the empty
humidifier bottle could cause dryness.
2. A review of an admission Record indicated the facility admitted Resident on [date] with a
diagnosis that included Chronic Obstructive Pulmonary Disease (COPD).
A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of
[date], revealed Resident had a Brief Interview for Mental Status (BIMS) score of 11, which
indicated the resident had mod…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
oxygen was administered at the ordered flow rate. She also indicated the night nurses were responsible for
changing out the humidifier bottles.
11
5
015032
[date]
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
(X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICI…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide safe and appropriate respiratory care for a resident when needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, review of the clinical record, facility documentation, facility policy and interviews for 4 of 4
residents (Residents #110, 368, 25, 39) reviewed for respiratory care, the facility failed to determine the
frequency with which oxygen and nebulizer tubing should be changed and implement such, and failed to
administer oxygen according to the physic…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
difficulty breathing. Interventions included providing oxygen, incentive spirometry, and checking pulse
oximetry as ordered and as needed.
The physician's order dated [date] directed to provide humidified oxygen at 2 liters per minute via nasal
cannula continuously every shift, titrate to keep saturation above 92%.
Observation on [date] at 11:20 AM identified Resident was sitting in his/her recliner chair wearing
oxygen at 1.5 liters via nasal canula. The oxygen tubing was without the benefit of a label/date as…
Accepted POC examples
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